210312 07/05/2012 CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
0 ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH MK AMOUNT: $945.00
CARMEL, INDIANA 46032 7169 SOLUTION CENTER
CHICAGO IL 60677 -7001 CHECK NUMBER: 210312
CHECK DATE: 7/512012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1082 4340700 321079 810.00 MEDICAL FEES
1091 4340700 321079 135.00 MEDICAL FEES
Community Occupational Health Services
7169 Solution Center
Chicago, IL 60677 -7001
Phone: 317- 621 -0337
FEIN: 35- 1955223
Invoice
June 05, 2012
Bill to: Lynn Russell For: Carmel Clay Parks Recreation
Cannel Clay Parks Recreation 5/12
1411 E. 116th St.
Cannel, IN 46032-
Invoice 321079
Proc Code ICD9 Date Description Qty Change Receipt Adjust Balance
746404 05/18/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Lauren Baney Balance Due: en 45.00
746404 05/17/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Joshua D Bourdo Balance Due: 45.00
746404 05/21/2012 Drug Screen Non N I DA 5 Panel 1.00 45.00 45.00
Brittani C Bush Balance Due: 45.00
746404 05/21/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Desirae Cal Balance Due: 4
746404 05/18/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Tyler S Coppotelli Balance Due:,, 45.00
746404 05/23/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Mary T Fata Balance Due: 4 5.0 0
746404 05/15/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 j� 45.00
Allison C Galloway Balance Due: 45.00
746404 05/19/2012 Drug Screen Non NIDA 5 Panel 1.00 45..'��0yy0 45.00
Elalie R Cif1i�Balance Due: 45.00
746404 05/17/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Janet C Karsas Balance Due: 4
746404 1) 847.2 05124/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
2) E927.0
Lisa L Keith Balance Due: 4 5. 00
146404 05/18/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Jeffrey C Lee Balance Due: 4
746404 05/22/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Invoice 321079 (continued) page 2
Mary McCaulay Balance Due: 45.00
746404 05/18/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Natalie A Meengs Balance Due: 45.00
746404 05/23/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Birgitta R Monson Balance Due: L 45.00
746404 05/21/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 (1 45.00
Christian A Moor Balance Due: 45.00
746404 1) 915.8 05/25/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
2) E920.8
Manchion Neely Balance Due: 45.00
746404 05/17/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Matthew W Petersen Balance Due: 45.00
746404 05/22/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Jane A Schreiner Balance Due: 4 5.00
746404 05/16/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Catherine E Surette Balance Due: 1 45.00
746404 05/29/2012 Drug Screen Non NIDA 5 Panel i.00 45.00 45.00
Carrie Williams Balance Due: 45.00
746404 05/23/2012 Drug Screen Non NIDA 5 Panel 1.00 45.00 ((t� 45.00
Hope R Woolsey Balance Due: 45.00
Invoice 321079 Balance Due: 945.00
PLEASE REMIT PAYMENT PROMPTLY
Purchase
Description V V P� J �ol VED i
P.O. P or F
JUN Q 2012
Budget
Line Descr B
Purchaser Date_ Z
Approval Date
3 V 0 7 00
9 Y3 Y 7 0
Cut and return with ayment
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bill to be properly itemized must show; kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
355031 Community Occupational Health Services Terms
7169 Solution Center
Chicago, IL 60677 -7001
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
6/5/12 321079 Pre-employment drug testing 135.00
6/5x12 321079 Pre= employment drug testing 810.00
Total 945.00
1 hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6
20_
Clerk- Treasurer
Voucher No. Warrant No.
355031 Community Occupational Health Services Allowed 20
7169 Solution Center
Chicago, IL 60677 -7001
In Sum of
945.00
ON ACCOUNT OF APPROPRIATION FOR
108 ESE 109 Monon Center
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1091 321079 4340700 135.00 1 hereby certify that the attached invoice(s), or
1082 -99 321079 4340700 810.00 bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
28 -Jun 2012
Signature
945.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund